Nurse led titration of guideline-directed medical therapy for heart failure in Italy: an operative flow chart
M Barisone, M Gori, V Rizzello, R De Maria, M Marchesi, D Pini, D Radini, E D'elia, L Fazzini, N Caples, P Ameri, A Di Lenarda, M Marini, M Senni, S CarigiAbstract
Background/Introduction
ESC guidelines recommend rapid tritation of guideline-directed medical therapy (GDMT) in heart failure (HF) to optimize outcomes. However, real-world implementation remins suboptimal owing to healthcare system barriers, patient-related factors, and therapeutic inertia, resulting in worse prognosis. Nurse-led titration offers a valid multidisciplinary solution, yet remains underutilized in Italy and several European countries, where the role and autonomy of heart failure (HF) specialist nurses are not yet formally recognized.
Objectives
To propose an operational flowchart for nurse-led GDMT titration in Italian HF clinics, informed by experiences at leading Italian referrral HF centers.
Methods
An operational flowchart for nurse-led GDMT titration was development by a panel of italian HF experts, drawing from clinical experiences at referral centers. It integrates multiprofessional protocols for post-discharge follow-up (nursing visits at 2/4/9 weeks; cardiologist at 6/12weeks), monitoring of key parameters (electrolytes, renal function, natriuretic peptides), validates titration steps with joint medical oversight, and PROMs/PREMs questionnaires to capture patient perspectives.
Results
Preliminary Italian experiences demonstrate the feasibility of nurse-led GDMT titration within multiprofessional models. At the Center 1 (Sub-center 1 : 35 patients Feb-Jun 2025; Sub-center 2: 408 patients Jan 2024-Jun 2025), 80% of patients achieved all four GDMT pillars by 9 weeks, with ≥ 50% target dose in 70% and 100% in 25%. At the Center 2 (52 patients Oct 2024- May 2025), 6 week results showed 75% at full beta-blocker target (89%≥ 50%), 17% at full ARNI/RASI target (64%≥ 50%), and 72% on quadruple therapy. At the Center 3 early post-discharge program enables nurse-proposed adjustment via shared algorithms with joint cardiologist sign-off.
Conclusions
Nurse-led GDMT titration, backed by training and protocols, enhances HF care in Italy without legal hurdles, aligning practice with guidelines and potentially cutting hospitalizations Europe-wide.For image description, please refer to the figure legend and surrounding text.